In the last decade, several studies have demonstrated the possibility of home treatment for selected haemodynamically stable patients with acute pulmonary embolism (PE). However, controversy persists about the optimal referral strategies and eligibility criteria for outpatient care. European guidelines recommend the Pulmonary Embolism Severity Index (PESI) score or the simplified PESI score (sPESI) to assess the risk of all-cause mortality.1 Patients with an sPESI score of 0 can be treated at home if adequate follow-up and anticoagulant therapy can be provided. American guidelines do not require a predefined score,2 and advise using pragmatic criteria such as those evaluated in the Hestia study.3
The open-label non-inferiority HOME-PE trial examined whether a strategy based on the Hestia criteria was at least as safe as a strategy based on the sPESI score to select patients for home treatment. In total, 1,974 patients with normal blood pressure who presented to the emergency department with acute PE were randomised. Patients in the sPESI group were eligible for outpatient care if their score was 0; otherwise they were hospitalised. Patients randomised to the Hestia group were eligible for outpatient care if all 11 criteria were negative; otherwise they were hospitalised. In both groups, the physician in charge could overrule the decision on treatment location for medical or social reasons.
The primary outcome of recurrent venous thromboembolism, major bleeding and all-cause death within 30 days occurred in 3.8% of patients in the Hestia group and 3.6% of patients in the sPESI group, with non-inferiority confirmed (p=0.005). A greater proportion of patients were eligible for home care using sPESI (48.4%) compared with Hestia (39.4%); however, physicians overruled sPESI more often than Hestia. Consequently, a similar proportion of patients were discharged within 24 hours for home treatment: 38.4% in the Hestia group and 36.6% in the sPESI group (p=0.42). All patients managed at home had a low rate of complications.
Prof. Roy summed up the results: “The pragmatic Hestia method was at least as safe as the sPESI score for triaging haemodynamically stable PE patients for outpatient care. These results support outpatient management of acute PE patients using either the Hestia method or the sPESI score with the option for physicians to override the decision. In hospitals organised for outpatient management, both triaging strategies enable more than a third of PE patients to be managed at home with a low rate of complications.”